Proposed model for electronic physiotherapy records in Belgium

Background: Anno 2012 Electronic Health Record (EHR) systems are generally accepted as the best way to store and manage the patient's medical record. Also in the physiotherapy domain EHR systems have been introduced many years ago. In Belgium several stand-alone software systems exist, but their purpose is limited. Functions such as patient administration, agenda management and invoicing exist, but all systems lack a clearly defined EHR structure and the possibility of data-exchange with other care takers. Moreover with the introduction of the electronic prescription in Belgium, systems will have to be ready to deal with coded and well-structured data.
Objective: The development generic structure for the physiotherapy record and a model to incorporated this structure in the currently available EHR systems in physiotherapy in Belgium.
Method: First the structure for the EHR was elaborated, based upon concepts of the International Classification of Functioning, Disability and Health (ICF). In a second phase a model for interoperability with colleagues and other care takers was designed.
Results: An internationally accepted, eight step structure, based upon the clinical reasoning of the physiotherapist was decided upon in a first phase, making use of first level ICF coding wherever possible. Secondly a model for the implementation of this structure into the different EHR systems on the Belgian market was designed. We opted for a web-based module that will be available for all vendors, to create a unique record structure, facilitating the interoperability between different systems. A lot of attention was paid to the integration with the Belgian eHealth-platform (offering basic services such as authentication and end-to-end encryption) and the use of Belgian as well as International standards.
Conclusion: The proposed model creates a generic structure for EHR systems in physiotherapy in Belgium, allowing exchange of prescriptions, treatment reports and possibly full patient records in the future, making use of available standards.